MIA96FA059

NTSB accident investigation · Douglas DC-9-32 · Nashville, TN · January 7, 1996

Accident · Minor injuriesClass 1 · FieldFinal report
Date
January 7, 1996, 16:20 local (22:20 UTC)
Place
Nashville, TN
Injuries
5 minor, 88 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N922VVDouglas DC-9-32
Weather
Visual (VMC) · Day
Status
Completed · report December 11, 1996
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Safety recommendations
Yes
FAA report
19960107000159A
Case key
37890

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the flight crew's improper procedures and actions (failing to contact system operations/dispatch, failing to use all available aircraft and company manuals, and prematurely resetting the ground control relay circuit breakers) in response to an in-flight abnormality, which resulted in the inadvertent in-flight activation of the ground spoilers during the approach to landing and the airplane's subsequent descent rate and excessively hard ground impact in the runway approach light area. Contributing factors in the accident were ValuJet's failure to incorporate cold weather nosegear servicing procedures in its operations and maintenance manuals, the incomplete procedural guidance contained in the ValuJet quick reference handbook, and the flight crew's inadequate knowledge and understanding of the aircraft systems.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionTakeoff - initial climb
Weather condition - temperature,low
Landing gear,nose gear strut - improper
Landing gear,gear switch - movement restricted
Emergency procedure - performedFlightcrew
Electrical system,circuit breaker - open
Loss of control - in flightApproach - faf/outer marker to threshold (ifr)
Checklist - inaccurateCompany/operator managementFactor
Planning/decision - improperFlightcrewCause
Circuit breaker - selectedFlightcrewCause
Lack of familiarity with aircraftFlightcrewFactor
Spoiler extension - inadvertent activationFlightcrewCause
In flight collision with terrain/waterLanding

Analysis

After takeoff, pilots (plts) had difficulty retracting landing gear (LG), & manually bypassed LG anti-retraction system to retract gear. While climbing, they realized cabin pressurization (CP) & takeoff warning (TW) systems were still in ground mode. (There was evidence nosegear shock strut was underserviced/underinflated for cold/winter weather operation; & strut did not extended sufficiently to actuate ground shift mechanism, to release landing gear lever anti-retraction mechanism, & to shift aircraft (acft) systems to flight mode.) Using quick reference handbook (QRH) procedures, plts pulled Ground Control Relay circuit breakers (C/Bs), then noted CP & TW began operating in flight (flt) mode. En route, the flt was uneventful. Plts decided to reset C/Bs just before touchdown. They made a normal approach to runway, & on short final approach, Captain reset C/Bs. At that time, ground spoilers activated, & acft descended rapidly, striking ground tail first in runway approach light area. Abnormal procedure in QRH stated 'GROUND CONTROL RELAY C/Bs (if pulled) . . . RESET . . . .' This was listed in 'Approach and Landing' section of procedure. Acft operating manual (AOM) stated 'Reset Ground Control Relay circuit breakers during taxi . . . .' Plts stated they had not referenced AOM, nor did they notify company of in-flight irregularity. (See: NTSB/AAR-96/07 for detailed info)

Factual narrative

For detailed information concerning this case, see the National Transportation Safety Board Blue Cover Report (NTSB/AAR-96/07).

Aircraft

Registration
N922VV
Reported as
Douglas DC-9-32
Category
Airplane
Serial number
47274
Airframe hours
1,776
Engine
P&W JT8D-9A, 14,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Valujet Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 7, 1996 · 4 hours before
Departed
ATL · Atlanta, GA
Destination
BNA
Flight plan
IFR
Airport
BNA · Nashville International, runway 2R, 8,000 × 150 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
4,381 total · 1,061 in this make and model · 1,212 as pilot in command · 167 in the last 90 days · 61 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 12 knots, gusting 20
Visibility
5 statute miles
Lowest ceiling
2,400 ft broken
Temperature
21 °F, dew point 14 °F
Altimeter
30.00 inHg
Observed at
BNA, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.